Jury: Hospital to blame for girl's brain damage

Story Published: Oct 9, 2008 at 11:12 PM PST

SEATTLE -- A jury verdict on Thursday awarded
$4.25 million to the family of a girl who was born with severe brain damage
following a traumatic delivery at Evergreen
Hospital in 2003.
Miriam Tavares, now 5, suffers from brain damage and cerebral palsy.
Her mother, Charla Tavares, said while lying in the hospital waiting to give
birth, she felt her daughter's heartbeat drop.
Charla's husband rushed to alert a nurse but, according to Charla, that's when
real trouble began.
"She (the doctor) had gone home for dinner and we had to wait for her to
come back," Charla said."There was no other doctor. There was no
other doctor on call."
Meantime, Miriam was deprived of oxygen for 20 minutes. A doctor finally
arrived and performed an emergency Cesarean section.
"I asked, you know, 'Is she OK?' And he (the doctor) said, 'It doesn't
look good,'" said Charla.
The jury found the Kirkland hospital ignored signs of severe fetal distress and
failed to notify a doctor in time, causing Miriam Tavares to asphyxiate for 20
minutes before an the C-section was performed.
The family's attorney, John Budlong, argued the nurses' failure to notify a
doctor in time delayed the Cesarean section and caused the girl's injuries.
However, the hospital denied any liability and claimed the injuries were
pre-existing.
After years of litigation and three days of deliberation, a jury agreed with
the plaintiff who claimed a timely Cesarean section could have prevented the
full-term infant's injuries.
Following the jury's decision on Thursday the hospital released a statement
which said Evergreen is not at fault for Miriam's impairment.
"Evergreen believes that the minor plaintiff's injuries had,
unfortunately, already occurred before her mother arrived at the
hospital."
The award includes compensation for past and future medical expenses, lost
future earnings and pain and suffering endured. However, an appeal could hold
up the award for up to two years.

Botched birth results in
federal lawsuit

9/30/2008 1:58 PM

By Kelly Holleran -Berkeley Bureau

MARTINSBURG - A Berkeley Springs woman has filed a federal suit on behalf of
herself and her son against City Hospital and the United States, claiming her son was
born with birth defects after doctors failed to deliver him in time.
Shannon Gregg went to the City Hospital Obstetrics Department on Nov. 13, 2000,
where she gave birth to her son, Michael Gilley, the following day, according
to a complaint filed Sept. 22 in U.S. District Court.
After Gregg entered the hospital, Lori Goforth, a midwife, administered a 25
microgram dose of Cytotec to induce labor on Nov. 13 at 9:50 a.m., the suit
states.
Gregg already had undergone a cesarean section on Sept. 10, 1999, and claims
she was not notified of the risks of a vaginal birth with Gilley.
Gregg claims that once she was given the dose, Gilley's heart rate dropped to
90 beats per minute at 10:47 a.m. and continued to stay that way until at least
5:15 p.m.
Throughout the same time, Gregg was experiencing cramps in her lower abdomen,
according to the complaint.
Gilley's heart rate was continually below the normal 130-range before Goforth
applied a spiral electrode at 12:08 a.m. Nov. 14 and found a moderate amount of
bloody fluid, according to the complaint.
Dr. H. Alexander Wanger was notified of Gregg's condition at about 12:10 a.m.
and came into the delivery room to perform a cesarean section, which he began
at about 12:30, the suit states.
"Upon entering the abdomen, it was observed that the uterus had ruptured
and the infant and placenta were in the peritoneal cavity," the suit
states.
Gregg claims that when Gilley was delivered "he was floppy, had no
respiratory activity, and no response to stimuli," according to the
complaint.
He was taken to the nursery and placed on a ventilator where he had multiple
myoclonic episodes as well as tonic-clonic episodes, the suit states.
Gregg claims Gilley now suffers from brain damage, developmental delay and
reflux.
Goforth, Wanger, the United States
and City Hospital were negligent because they
failed to properly monitor and treat Gregg's labor, failed to advise Gregg of
the risks to her baby if vaginal delivery was attempted, failed to use the
proper medication and delayed responding to Gregg's need for a cesarean section,
according to the complaint.
In addition, both City Hospital and the United States government had a duty
to provide competent and quality medical care and treatment and to continually
survey the professional performance of its staff members, the suit states.
Wanger and Goforth are employees of the United States, according to the
complaint.
Gregg is seeking unspecified economic and non-economic damages, pre-judgment
interest, costs and attorney fees.
Barry J. Nace of Paulson & Nace in Washington,
D.C., and D. Michael Burke of
Burke, Schultz, Harman & Jenkinson in Martinsburg will be representing
Gregg.

In the mid-1990s, the authors introduced a minimally invasive system of cesarean delivery. This article illustrates the improvements made since the technique's initial publication. The Pelosi Minimalist Cesarean procedure is the simplest and least traumatic approach of cesarean delivery. The procedure described herein features a short operating time, minimal instrumentation, reduced surgical dissection, decreased postoperative pain, and reduced risk of blood loss, infection, and wound complications. It is easily learned and cost-effective, with a brief postoperative recovery period.

July 2004 • Vol. 16, No. 7Minimally invasive cesarean:Improving an innovative techniqueShort operative time, less surgical dissection, and reduced risk of infection are among the advantages of this newly updated procedure.

MARCO A. PELOSI II, MD; MARCO A. PELOSI III, MDDr. Pelosi II is director and Dr. Pelosi III is associate director, Pelosi Women’s Medical Center, Bayonne, NJ. Dr. Pelosi II also serves on the OBG MANAGEMENT Board of Editors.KEY POINTS• A simplified abdominal incision makes the traditional extensive dissection associated with the Pfannenstiel incision unnecessary.• A soft, self-retaining abdominal retractor offers increased exposure, atraumatic retraction, incision protection, and adjustable height while facilitating delivery of the fetal head by creating a rigid border around the abdominal incision.Bladder-flap omission has been associated with reduced operative time and incision-delivery interval, decreased blood loss, and less need for postoperative analgesicsIs the extensive dissection of the Pfannenstiel incision necessary in cesarean delivery? Is bladder dissection essential? Must the visceral and parietal peritoneum be closed? The success of our minimally invasive cesarean technique suggests the answer is “no.”The approach described here features a short operative time; minimal instrumentation; reduced surgical dissection; decreased postoperative pain; and reduced risk of blood loss, infection, and wound complications. It is easily learned and cost-effective, with a brief postoperative recovery period.Among the updates made from the technique’s initial publication in the mid-1990s1,2:• addition of routine perioperative oxygen (80%), to reduce the risk of surgical wound infection • regular use of forced warm air covers applied to the anterior skin surface, to help patients maintain normothermia• addition of a soft, self-retaining abdominal retractor—which creates an atraumatic circle of exposure up to a calculated 177 cm2 for a 15-cm incision (versus 113 cm2 calculated for traditional retraction)• vertical, rather than lateral, digital extension of the initial transverse uterine incision• identification of a subgroup in whom peritoneal closure is strongly recommended• new data on the procedure’s effectiveness.3Perioperative considerationsRoutinely use prophylactic antibiotics. Several recent studies have concluded that perioperative antibiotics reduce the incidence of endometritis and wound infection following elective and nonelective cesarean section.37 Administer ampicillin or a first-generation cephalosporin at umbilical cord clamping. For patients allergic to penicillin and cephalosporins, choose an alternative, such as clindamycin.Give antacids 30 minutes before anesthesia (general or regional) to prevent pneumonitis from inhalation of gastric contents.Clip pubic hair, rather than shave, to reduce the risk of wound infection.Insert a Foley catheter, empty the bladder, and keep the catheter in place.Position the patient in a 10°left lateral tilt, to avoid hypotension associated with aortocaval occlusion.Routinely administer supplemental perioperative oxygen (80%), with either general or regional anesthesia; this activates alveolar immune defenses and halves the risk of surgical wound infections.Neutrophil oxidative killing and phagocytosis—the most important defenses against surgical pathogens—depend on the partial pressure of oxygen in contaminated tissue. Giving supplemental oxygen during and for the first 2 hours after the procedure (by mask) is a practical, inexpensive way to reduce the incidence of surgical wound infection.38,39Using 80% oxygen during and, for a short period, after surgery does not cause pulmonary toxicity such as atelectasis or impaired pulmonary function.40Ensure normal body heat during and after cesarean to reduce the risk of postoperative surgical infection.40,41 Forced warm air covers applied to the anterior skin surface are the most effective way for warming surgical patients.9 IV fluid warming, though appropriate when large volumes are to be administered, is unnecessary for smaller operations.41Modified abdominal incision reduces dissectionMake a straight low transverse incision with a scalpel, at a point approximately 3 to 4 cm above the symphysis pubis.The length of the incision is individualized (13 to 15 cm), though difficult fetal extraction is more likely if the abdominal incision is less than 15 cm.4,5Divide the subcutaneous tissue transversely with an electrocautery knife. In a cutting and coagulation blend mode, the knife divides the fat while achieving hemostasis. To improve hemostasis, coagulate the blood vessels that cross the subcutaneous fat layer in a brushing manner before dividing them. To prevent unnecessary dead space, avoid filleting the fat and separating adherent subcutaneous fat from the anterior rectus fascia beyond what is needed to expose the fascia.Open the fascia transversely with the electrocautery knife to the same length as the skin incision. Coagulate the blood vessels that cross the fascia before dividing them. Identify the median raphe by pulling up the superior edge of the abdominal incision.Separate the rectus muscles in the midline by vertical blunt finger dissection. If digital dissection is inefficient due to a dense, thick, or scarred median raphe, use an electrocautery knife, a scalpel, or scissors.Open the peritoneum. This is facilitated by upward traction and elevation of the superior edge of the abdominal incision that lifts the peritoneum, allowing easy digital perforation using the index or middle finger.If this maneuver is not feasible, open the peritoneum in the traditional fashion.Stretch the full thickness of the abdominal wall to full size of the skin incision, using 1 or 2 fingers of each hand. Incorporate the skin, subcutaneous tissue, fascia layer, rectus muscles, and peritoneum. An assistant’s hands may be required. When needed, extend the peritoneal opening transversely on either side, to the midline and away from the bladder.Digitally stretching the full-thickness abdominal incision is easily achieved due to the mechanical stretching of the anterior abdominal wall, edema, and increased vascularization that occur during pregnancy.Retractor facilitates exposureOur positive experience with the soft, self-retaining abdominal retractor for minilaparotomy and laparotomy6-8 compelled us to incorporate its use for cesarean 3 years ago.The device consists of a flexible plastic inner ring and a firmer outer ring connected by a soft plastic sleeve. We use the large size of either of the 2 models currently available: the Mobius (Apple Medical Corporation, Marlboro, Miss) and the Protractor (Weck Closure Systems, Research Triangle Park, NC).Introduce a hand through the laparotomy incision and evaluate the pelvis to ensure that no significant adhesions are present that may interfere with swift placement of the inner ring. If significant adhesions are found, use traditional metal retractors instead.Squeeze the inner ring and insert it into the abdominal cavity toward the patient’s head, allowing the device to spring open against the parietal peritoneum. Apply upper traction and elevate the superior edge of the abdominal incision to facilitate placement. Perform a digital check to ensure no tissue is trapped between the inner ring and the abdominal wall.Hold up the outer ring, then roll the plastic sleeve until the ring completely inverts. Repeat the process until the top ring is snug against the patient’s skin.Advantages of the soft, self-retaining abdominal retractor include atraumatic retraction; incision protection; and adjustable height, making it ideal for obese patients.Transverse hysterotomy in lower uterine segmentMake a transverse 2-cm uterine incision with a scalpel, approximately 1 cm above the vesicouterine peritoneal fold (identify this using gentle digital pressure to elevate the uterus).Traditional bladder dissection is eliminated. We have found that when an adequate transverse hysterotomy is performed, a bladder flap is not required.1-3 In a recent randomized trial, Hohlagschwandtner et al9 confirmed our findings that bladder-flap omission was associated with reduced operative time and incision-delivery interval, decreased blood loss, and less need for postoperative analgesics.An additional advantage of this omission: We can avoid making the uterine incision too low—especially when the cervix is fully dilated. Further, making the hysterotomy (uterine serosa and myometrium together) slightly above the vesicouterine peritoneal fold without bladder flap dissection frees the loose connective tissue between the uterus and the urinary bladder, allowing the spontaneous descent of the bladder.Digitally extend the transverse uterine incision. We extend the initial incision not laterally but, instead, vertically. The vertical digital traction on the initial transverse uterine incision creates a transverse dissociation of the horizontal myometrium fibers; this results in a transverse extension of the original incision.This modification prevents unintended and uncontrolled lateral extensions of the incision that may lacerate the uterine vessels.10 It also prevents the uterine incision from becoming an inverted “U” and the undesirable accumulation of myometrium fibers at the ends of the incision. Such incisions usually do not reapproximate well during hysterotomy closure and may lead to sacculation-type defects.11Delivering the fetusFor vertex presentations, place your hand into the uterine cavity between the lower edge of the hysterotomy and fetal head. While applying transabdominal fundal pressure, lift the head with your fingers and deliver it through the incision.The self-retaining retractor facilitates delivery of the fetal head by creating a rigid border around the abdominal incision. The back of the surgeon’s hand that is in the uterine cavity achieves better leverage, as it now rests on a rigid plane on the inferior part of the incision rather than on the back hand and the softer and pliable wound edge of the standard abdominal incision.Vacuum-assistance. When delivery of the fetal head proves difficult, we use the soft vacuum cup, which avoids unnecessary intrauterine manipulation that may result in fetal or maternal trauma.12Breech extraction or transverse lie delivery is performed using standard extraction maneuvers.13 We have found no need to perform T or J vertical extensions of the low transverse uterine incision, even in cases of a poorly developed lower uterine segment, abnormal presentation, or prematurity.Uterine incision: 1-layer, in situ closeRemove the placenta only after it separates spontaneously—this greatly reduces blood loss compared with immediate manual placental delivery or umbilical-cord traction. Manually deliver the placenta only if it has not separated spontaneously after 5 minutes. Avoid routine manual clean-out of the uterine cavity if the placenta is completely delivered.1-3,14Dilate the cervix to facilitate lochial discharge, when necessary.Decrease uterine bleeding by massaging the uterus and administering diluted oxytocin.Close the uterine incision in situ. Disadvantages of routine uterine exteriorization include discomfort and vomiting resulting from traction, exposure of the fallopian tubes to unnecessary trauma, increased risk of infection, possible rupture of the uteroovarian veins, and pulmonary embolism.Exteriorization may also increase the risk of adhesion formation by exposing the uterine serosa to the abrasive effects of drying or microscopic abrasion if sponges are used to hold the uterus in place.1,14-17Use a single-layer closure with a running suture of polyglycolic acid to close the uterine incision. If needed, use atraumatic clamps to grasp the edges of the hysterotomy to facilitate visualization and closure.Begin suturing at a point just beyond one end of the incision, continuing to the opposite side. Be sure to penetrate the full thickness of the myometrium and avoid incorporating the decidua in the suture line. After the uterine closure, use individual figure-of-8 sutures to control areas of persistent bleeding.Compared with 2-layer closures, single-layer closure of a low transverse incision is associated with reduced operating time, improved hemostasis, and less tissue disruption; introduces less foreign material into the surgical site; reduces the need for postoperative analgesia; and potentially reduces infectious morbidity. A trial of labor after a cesarean section with 1-layer closure appears safe.18-22We do not close the vesicouterine fold and parietal peritoneum or reapproximate the rectus muscles. It has been shown that a new peritoneal layer is formed within days of the original incision closure.Leaving the peritoneum open leads to no increased postoperative complications, nor obvious differences in wound healing, wound dehiscence, or incidence of postoperative adhesions. Compared to women without peritoneal closure, those with peritoneal closure require a longer operative time, greater amounts of post-operative narcotics for postoperative pain, a greater need for bowel stimulants, and a longer postoperative hospitalization.23In 1995, we performed laparoscopy for gynecologic conditions in 23 patients and repeat cesarean in 10 patients who had undergone our technique (with visceral and parietal peritoneum left open).2 We found no adhesions and a normal peritoneal lining in all cases.In 1 subgroup, peritoneal closure is strongly recommended: cases in which 1 or both rectus muscles have been transected to increase surgical exposure. Extremely thick fibromuscular adhesions between the low anterior surface of the uterus and the under-surface of the rectus musculature may develop if the parietal peritoneum is not closed.Abdominal closureClose the rectus fascia with a continuous nonlocking 0 suture after the rectus muscles fall into place. Place entry and exit sites at 1-cm intervals, 1.5 cm beyond the wound edges—this minimizes the risk of sutures pulling through fascia. Interrupted sutures offer no greater tensile strength than continuous suturing.24 Tight, continuous suturing can lead to tissue ischemia, which may weaken the sutured fascia, and thus should be avoided.The subcutaneous layer is not closed separately. One exception is obese patients with at least 2 cm of thick subcutaneous tissue. Thickness of subcutaneous tissue appears to be a significant risk factor for wound infection after cesarean section.25In patients with thick subcutaneous tissue, you can reduce tension on the skin edges and the risk of subcutaneous infection, seroma formation, and wound disruption by placing interrupted 3-0 absorbable synthetic sutures to eliminate dead space.26-28 We have found no need to place Penrose drains or closed drainage systems in the subcutaneous layer.29-31Close the skin using a subcuticular continuous absorbable 4-0 suture or, alternatively, metal staples, which are removed 4 days after surgery.Prompt postoperative recoveryThe patient may drink fluids in the recovery room, can resume a regular solid food diet within 4 hours after surgery, and may resume mobility as soon as anesthesia wears off.Early breast-feeding is also allowed in the recovery room. In our experience, this has not been associated with complications, has been highly appreciated by the patients, and has led to earlier hospital discharge.Control pain with meperidine (50–75 mg) or morphine (10 mg) parenterally every 3 to 4 hours. Other options include oxycodone and acetaminophen, oxycodone and aspirin, and ibuprofen.Patients are usually discharged 48 to 72 hours following surgery.Our experience: The numbersUsing this updated system, we have successfully completed 300 consecutive cesarean sections (210 primary, 90 repeat).The average operating time was 19 minutes; average blood loss, 405 mL.There was no postoperative febrile morbidity, wound infection, wound disruption, or wound hematoma. Only 3 patients developed superficial wound seromas, which were easily resolved. There were no intraoperative or postoperative complications.We attribute the absence of wound infection to routine prophylactic antibiotics; supplemental perioperative oxygen; maintenance of normothermia; use of an electrocautery knife to create rapid hemostatic division of subcutaneous fat and anterior rectus fascia; a simplified abdominal wall opening; and placement of a self-retaining atraumatic retractor.10,32-36Additional surgical procedures (tubal sterilization, myomectomy, appendectomy, and adhesiolysis) did not alter the recovery period, and all patients were able to get out of bed, shower, breast-feed, and care for their infants within 8 hours of surgery.No infant complications related to the cesarean procedure occurred.Patients were discharged from the hospital within 72 hours.A prospective comparison study demonstrated that the original Pelosi-type of cesarean delivery was faster to perform, more cost-effective, and resulted in less maternal morbidity than the traditional cesarean technique.3Dr. Pelosi II is a consultant for Apple Medical Corporation. Dr. Pelosi III reports no financial relationships relevant to this article.REFERENCES1. Pelosi MA, Ortega I. Cesarean section: Pelosi simplified technique. Rev Chil Obstet Gynecol. 1994; 59: 372 –377.2. Pelosi MA II, Pelosi MA III. Simplified cesarean section. Contemp OB/GYN. 1995; 40: 89 –100.3. Wood RM, Simon H, Oz AU. Pelosi-type vs traditional cesarean delivery: a prospective comparison. J Reprod Med. 1999; 44: 788 –795.4. Finan MA, Mastrogiannis DS, Spellacy WN. The “Allis” test for easy cesarean delivery. Am J Obstet Gynecol. 1991; 164: 772 –775.5. Ayers IW, Morley GW. Surgical incision for cesarean section. Obstet Gynecol. 1987; 70: 706 –712.6. Pelosi MA II, Pelosi MA III. Self-retaining abdominal retractor for minilaparotomy. Obstet Gynecol. 2000; 96: 775 –778.7. Pelosi MA II, Pelosi MA III. Pelosi minilaparotomy hysterectomy: Effective alternative to laparoscopy and laparotomy. OBG Manag. April 2003; 16 –33.8. Pelosi MA II, Pelosi MA III. A novel minilaparotomy approach for large ovarian cysts. OBG Manag. February 2004:; 17 –30.9. Hohlagschwandtner M, Ruecklinger E, Husslein P , et al. Is the formation of a bladder flap at cesarean necessary? A randomized trial. Obstet Gynecol. 2001; 98: 1089 –1092.10. Ferrari A, Frigerio L, Origoni M , et al. Modified Stark procedure for cesarean section. J Pelv Surg. 1996; 2: 239 –244.11. Field CS. Surgical techniques for cesarean section. Obstet Gynecol Clin North Amer. 1988; 15: 657 –672.12. Pelosi MA, Apuzzio J. Use of the soft, silicone obstetric vacuum cup for delivery of the fetal head at cesarean section. J Reprod Med. 1984; 29: 289 –292.13. Pelosi MA, Apuzzio J, Fricchione D , et al. The intra-abdominal version technique for delivery of transverse lie by low segment cesarean section. Am J Obstet Gynecol. 1979; 135: 1009 –1012.14. Magann EF, Dodson MK, Albert JR , et al. Blood loss at the time of cesarean section by method of placental removal and exteriorization versus in situ repair of the uterine incision. Surg Gynecol Obstet. 1993; 177: 389 –392.15. Stock RJ, Shelton H. Fatal pulmonary embolism occurring 2 hours after exteriorization of the uterus for repair following cesareans section. Milit Med. 1985; 150: 549 –550.16. Hershey DW, Quilligan EJ. Extra-abdominal uterine exteriorization at cesarean section. Obstet Genecol. 1978; 52: 189 –191.17. Wahab MA, Karantzis P, Eccersley PS , et al. A randomized, controlled study of uterine exteriorization and repair at cesarean section. Br J Obstet Gynecol. 1999; 106: 913 –916.18. Hauth JC, Owen J, Davis RO. Transverse uterine incision closure: one versus two layers. Am J Obstet Gynecol. 1992; 167: 1108 –1111.19. Ohel G, Younis JS, Lang N , et al. Double-layer closure of uterine incision with visceral and parietal peritoneal closure: Are they obligatory steps of routine cesarean sections? J Matern Fetal Med. 1996; 5: 366 –369.20. Tucker JM, Hauth JC, Hodgkins P , et al. Trial of labor after a one- or two-layer closure of a low transverse uterine incision. Am J Obstet Gynecol. 1993; 168: 545 –546.21. Chapman SJ, Owen J, Hauth JC. One- versus two-layer closure of a low transverse cesarean: the next pregnancy. Obstet Gynecol. 1997; 89: 16 –18.22. Jelsema RD, Wittinger JA, Vander Kolk KJ. Continuous, nonlocking, single-layer repair of the low transverse uterine incision. J Reprod Med. 1993; 38: 393 –396.23. Tulandi T, Al-Jaroudi D. Nonclosure of peritoneum: a reappraisal. Am J Obstet Gynecol. 2003; 189: 609 –612.24. Fagniez PL, Hay JM, Lacaine F. Abdominal midline incision closure. Arch Surg. 1985; 120: 1351 –1355.25. Vermillion ST, Lamoutte C, Soper DE , et al. Wound infection after cesarean: effect of subcutaneous tissue thickness. Obstet Gynecol. 2000; 95: 923 –926.26. Naumann RW, Hauth JC, Owen J , et al. Subcutaneous tissue approximation in relation to wound disruption after cesarean delivery in obese women. Obstet Gynecol. 1995; 85: 412 –416.27. Cetin A, Cetin M. Superficial wound disruption after cesarean delivery: effect of the depth and closure of subcutaneous tissue. Int J Gynaecol Obstet. 1997; 57: 17 –21.28. Del Valle GO, Combs P, Qualls C , et al. Does closure of Camper fascia reduce the incidence of post-cesarean superficial wound disruption? Obstet Gynecol. 1992; 80: 1013 –1016.29. Loong RL, Rogers MS, Chang AM. A controlled trial of wound drainage at cesarean section. Aust NZ J Obstet Gynaecol. 1988; 28: 266 –269.30. Saunders NJ, Barclay C. Closed suction wound drainage and lower-segment cesarean section. Br J Obstet Gynaecol. 1988; 95: 1060 –1062.31. Magann EF, Chauhan SP, Rodts-Palenik S, Bufkin L, Martin JN Jr, Morrison JC. Subcutaneous stitch closure versus subcutaneous drain to prevent wound disruption after cesarean delivery: a randomized clinical trial. Am J Obstet Gynecol. 2002; 186: 1119 –1123.32. Stark M, Finkel AR. Comparison between the Joel-Cohen and Pfannenstiel incisions in cesarean section. Eur J Obstet Gynecol Reprod Biol. 1994; 53: 121 –122.33. Joel-Cohen S. Abdominal and vaginal hysterectomy. New techniques based on time and motion studies. London, England: William Heinemann Medical Books; 1972.34. Hemsell DL, Hemsell PG, Nobles B , et al. Abdominal wound problems after hysterectomy with electrocautery versus scalpel subcutaneous incision. Infect Dis Obstet Gynecol. 1993; 1: 27 –30.35. Johnson CD, Serpell JW. Wound infection after abdominal incision with scalpel or diathermy. Br J Surg. 1990; 77: 626 –629.36. Hussain SA, Hussain S. Incisions with knife or diathermy and postoperative pain. Br J Surg. 1988; 75: 1179 –1182.37. American College of Obstetricians and Gynecologist. ACOG Practice Bulletin. Clinical management guidelines for obstetricians-gynecologists. No. 43, May, 2003. Management of preterm labor. Obstet Gynecol. 2003; 101: 1039 –1047.38. Greif R, Akca O, Hurn E-P , et al. Supplemental perioperative oxygen to reduce the incidence of surgical wound infection. N Engl J Med. 2000; 342: 161 –167.39. Sorensen LT, Karlsmark T, Gottrup F. Abstinence from smoking reduces incisional wound infection: a randomized controlled trial. Ann Surg. 2003; 238: 1 –5.40. Sessler DI, Akca O. Preventing surgical site infections without drugs. Contemp OB/GYN. 2004; 49: 78 –87.41. Kurz A, Sessler DI, Lenhardt R. Perioperative normothermia to reduce the incidence of surgical wound infection and shorten hospitalization. N Engl J Med. 1996; 334: 1209 –1215.

For four decades Israel has been sharing its
experience and expertise with other countries, notably but not solely with
developing countries whose growth and progress is hampered by limited
resources, financial restraints and lack of access to new and innovative
techniques and technology.

Under the aegis of MASHAV, Israel's Ministry of Foreign Affairs Centre for
International Cooperation, knowledge and know-how are transmitted through
courses, workshops and individual training programs, given - in Israel
and abroad - in fields as diverse as agriculture, community development,
cooperation and labour studies, education, science and technology, rural
development and medicine and public health. Much of MASHAV's success lies in
the way it is able to attract professionals and experts in these fields, with
years of experience and impressive backgrounds, to run these courses - to
lecture, teach and train.

Dr. Michael Stark, Director of the Misgav Ladach General Hospital
in Jerusalem,
is one of those experts. He has perfected a state-of-the-art birthing method
for performing Caesarean sections that is proving to be safer and simpler than
those performed in the traditional, conventional manner. Named after the
hospital where it was first introduced, the Misgav Ladach Method is now being
used in medical centres in Switzerland,
Sweden, Italy, Germany,
United States, Russia, Ethiopia,
Kenya, Tanzania, Zambia,
Uganda, India, Pakistan,
China and Peru.

A Caesarian section (C-section for short)
is defined as "the surgical removal of the foetus (the unborn infant) from
the uterus (womb)." Its use is indicated when either or both the mother
and the unborn infant are at risk and normal delivery is then both dangerous
and often impossible.

Dr. Stark insists that he did not
"invent" the Misgav Ladach Method although he must be credited with
the way he "took ideas from many different sources" and put together
an impressive package of refinements.

"Essentially," he stresses,
"the method is a synthesis of several techniques, notably those developed
by Prof. S. J. Joel Cohen, formerly of South
Africa, whom I met in 1972 in Vienna where I was a rotating intern and he
was a guest lecturer. I had previously read about his work and was deeply
impressed by his methods, especially his time and motion studies in
gynaecological operations." Later Dr. Stark would meet Prof. Joel Cohen
again in Israel at Beilinson Hospital when Prof. Joel Cohen became
Head of Obstetrics and Gynaecology "and I had the privilege of working
with him."

"The Misgav Ladach Method is basically
quite a simple one," explains Dr. Stark, "which eliminates many of
the conventional steps taken in traditional Caesarian sections. The result: The
procedure takes very little time, simply because fewer steps are performed. I
use the Joel Cohen Method of opening the abdomen. A traditional C-section may
take from a half to a full hour. Using our method, the operation lasts from 8
to 15 minutes, with the infant often emerging in less than one minute.

"In summary, the operation is much
less traumatic for the mother than a traditional C-section and her recovery is
extraordinarily rapid." Proof of this claim came when Shalom's reporter
talked with one of Dr. Stark's patients, a woman who, less than 24 hours before
the meeting, had had her fourth Caesarian. "It all went so fast," she
exclaimed. "After just two minutes I heard the baby crying. (N.B. "In
actual fact," reports Dr. Stark, "it was 50 seconds.")

"After my first Caesarian, a
traditional one performed in the USA, I had terrible pain. Then I
was hooked up to an infusion apparatus and for two days couldn't eat or drink
normally. I was also in bed for almost a week. The operation yesterday was
entirely different, an exciting experience in so many ways. I could eat and
drink everything immediately after it and, within a few hours I was up and
around, could even bend down and pick things up off the floor."

Dr. Stark points out other benefits to the
mother. "Not only does she have less pain and thus less need for
painkillers, but there is less if any fever following the operation and thus
less need for antibiotics. There is a shorter period for the return of normal
bowel functions, fewer adhesions to the peritoneum (the membrane that lines the
cavity of the abdomen), less scarring to the abdominal layers and less
bleeding. The rapidity of the operation also means that less anaesthesia is
required. Overall there are fewer short and long-term complications."

The benefits to the patient carry over to
hospitals and their personnel. First, since there is less cutting, less
bleeding and less suturing with fewer instruments, there is less of a chance of
surgeons sustaining a wound during the operation. This is especially significant
in settings where there is a high frequency of HIV (the virus that causes AIDS)
and nurses and doctors run the risk of getting the virus from a patient. With
the Misgav Ladach Method, this risk in minimized. Second, the speed with which
the operation can be performed due to fewer steps saves both operating room and
staff time.

The story behind the Misgav Ladach Method
is as fascinating as the method itself. Michael Stark is an accomplished
pianist, a graduate from the Jerusalem Conservatory of Music. "In
music," he says, "I regards myself as an aesthetic minimalist, one
who is always looking for the most simple techniques, for the way to play as
smoothly and as effortlessly as possible. Thus when I began to search in the
literature for ways to improve C-section operations, I looked for material
written by those whose approach was minimalistic - in theory and practice.

"My ideas, my whole general approach
is based first of all on this philosophical principle of surgical minimalism. I
believe in using only those surgical manoeuvres that are vitally necessary,
those which are least disruptive to the tissues. If you can do something
simply, you don't need to do it in a complex way. That is why, for example, I
suture the uterus with one layer rather than two and close the abdomen with two
layers rather than the traditional five."

Although Dr. Stark claims that the Misgav
Ladach Method is not an original concept, there are original elements in it
which he has designed. The way he sutures the uterus is one. So too is a
special needle he has invented, as well as a unique method for handling the
urine bladder.

Dr. Stark also follows another
philosophical principle: Work in harmony with the body's anatomy and
physiology. "Thus," he explains, "in the Misgav Ladach Method,
the level of the skin incision and the levels of separation of the recti
muscles are carefully chosen to be well away from muscle insertion sites. The
result: Less force is needed at separation and there is less disruption to the
vulnerable blood vessels and nerves near the site of the muscle fixation,
similar to the way it is easier to pluck the strings of a string instrument in
the middle rather than at the far ends."

The Misgav Ladach Method is currently being
tested in multi-centre randomized controlled trials in Sweden, Italy
and Kenya.
Non-randomized comparative studies have already been done in Israel and Switzerland.

Sweden
has played a dominant role in spreading the word about the method to low-income
countries. The Swedish medical journal NU, in which a lengthy description of
the method appeared, has been sent to 119 countries. "In Israel we ourselves are actively in
contact with 22 countries," reports Dr. Stark. He has personally visited
many of them - lecturing, operating and observing other doctors put into
practice the method they have learned from him.

For the past two years many of Dr. Stark's
trips abroad have been within the framework of Israel's program of international
cooperation. Some of his on-the-spot workshops, such as those held in Hungary and Slovenia, were only two to three
days long. Nevertheless, they were sessions of intense and concerted activity.
Much was accomplished as doctors watched Dr. Stark operate and then followed
suit, performing under his direction C-section operations according to the
Misgav Ladach Method.

Last fall (1996) MASHAV sent Dr. Stark to China where in eight days of marathon activity
he gave workshops and lectured on C-section and gynaecological oncology in two
cities - Beijing
and Daxing - for hundreds of doctors. This trip was followed by a return visit
by two of Chinese professors from the first academic hospital in Beijing who came to the Misgav Ladach
Hospital for further
training.

This winter (1997) Dr. Stark's schedule
included visits to Georgia, Kyrgistan and Kazakhstan where, accompanied by a
Russian-speaking doctor from Israel who served as his interpreter and
assistant, he again introduced the method that is being lauded the world over.

Letters have arrived testifying to the
efficacy of the method. A doctor in Karachi,
Pakistan, for
example, wrote how reading about the Misgav Ladach Method in a medical journal
led him to use it. "Already," he wrote, "I have performed 51
C-sections following the guidelines given in the journal. I work on a busy
hospital that has very limited resources, as does the very low socio-economic
population we serve. I find this method fast, with minimal blood loss and with
minimum expense for hospital and patient. This is a significant and useful
advantage for any hospital in any country, but especially for hospitals such as
ours which have limited resources."

Similarly enthusiastic was a doctor from Bihar, India.
In his letter he wrote that he had performed his last 5 C-sections according to
the Misgav Ladach Method, again after reading about it in a medical journal.
"I feel that it is the single most important development in obstetrical
surgery since Munro-Kerr discovered the lower-segment incision in 1911."

And from Uganda a doctor ended his letter
with the following words: "I have only praise for the way the method is so
painless - for doctor and patient."

Dr. Stark began work on what it is known as
the Misgav Ladach Method over 10 years ago. It soon became an on-going
evolutionary process of constant refinement and improvement "with the last
major change made just five years ago." This does not mean, however, that
he has ceased to search for new improvements, for ways to make it even safer,
simpler and more efficient - for he hasn't.

In the world of music, great artists
constantly search for ways to re-interpret the pieces they play, continually
strive to perfect their performance. Those Michael Stark admires the most are
those who, as he, seek out the simplest techniques to achieve maximum effect.
He has transferred this concept to his work in medicine, with effective and
salutary results.

Equally noteworthy, he is an inveterate
world traveler, deeply committed to sharing his knowledge with doctors all
over. His missions abroad typify the way Israel, long a leader in the field
of international cooperation, helps others to help themselves.

Mandatory Obstetric Photography (MOP)

Birth Pangs announces today that it is embarking on a new campaign,
Mandatory Obstetric Photography (MOP).

To help pre-pregnant women understand fully the long-term, serious
consequences of pregnancy, we propose a law that requires pre-pregnant women to
have Mandatory Obstetric Photography. The women would strip naked for a series
of full-body, harshly lit photographs. Special attention would be paid to perky
breasts, tidy hips, and taut skin. Then the women must look at the photos.
Before becoming pregnant, all women would be required to sign an affidavit that
they had seen the photos and understand that they will never look like that
again.

To give credit where credit is due, we stole this idea from our
fetus-fetishizing friends in South
Carolina, who this week pressed forward a bill that
would require all women seeking abortions to have ultrasounds and then swear
they had seen said ultrasounds. From an AP story:

COLUMBIA, S.C. – With calls of emotional blackmail
from opponents, a measure requiring women seeking abortions to first review
ultrasound images of their fetuses advanced Wednesday in the South Carolina
Legislature.

The legislation, supported by Republican Gov. Mark Sanford, passed 91-23
after lawmakers defeated amendments exempting rape or incest. The House must
approve the bill again in a routine vote before it goes to the Senate, where
its sponsor expects it to pass with those exemptions.

Some states make ultrasound images available to women before an abortion,
but South Carolina
would be alone in requiring women to view the pictures.

Critics consider the proposal a tool to intimidate women who already have
made an agonizing decision.

“You love them in the womb but once they get here, it’s a different story,”
said Rep. Gilda Cobb-Hunter, a Democrat and a social worker. “You’re sitting
here passing judgment? Who gave you the right?”

Proponents hope women will change their minds after seeing an ultrasound.

Now, note that the Birth Pangs initiative, while just as coercive and
manipulative, does not require ultrasound. That’s because we, unlike
legislators in various USian states, take warnings from various medical
organizations, including the US Food and Drug Administration, seriously.

In the January/February 2004 issue of its Consumer Magazine, the USian FDA
cautions against ultrasound for non-medical reasons.

While ultrasound has been around for many years, expectant women and their families
need to know that the long-term effects of repeated ultrasound exposures on the
fetus are not fully known. In light of all that remains unknown, having a
prenatal ultrasound for non-medical reasons is not a good idea.

Still, ultrasound is a form of energy, and even at low levels, laboratory
studies have shown it can produce physical effects in tissue, such as jarring
vibrations and a rise in temperature. Although there is no evidence that these
physical effects can harm a fetus, the FDA says the fact that these effects
exist means that prenatal ultrasounds can’t be considered completely innocuous.

Note the absence of ‘manipulating women by emotional blackmail into
continuing a pregnancy they do not want’.

Other organizations also disapprove of non-medical uses of ultrasound,
including the American Institute of Ultrasound in Medicine, the European
Committee for Medical Ultrasound, Canadian Society of Diagnostic Medical
Sonography, Ontario Medical Association, and in February 2007, the British
Medical Ultrasound Society (BMUS) also weighed in. In a widely reported story, Reuters
quotes Dr. Kevin Martin, BMUS president:

The society feels that ultrasound was developed and is intended for medical
diagnosis and any such scans should be endorsed by a medical practitioner.

Here is what Wikipedia has to say about the dangers of ultrasound:

The safety of ultrasonography has been studied extensively. All medical
procedures have beneficial consequences with risk for detrimental consequences.
However, the important question is: what is the balance between the two?

Ultrasound does have bio-effects. Usually these are in some proportion to
the amount of energy put into in the tissue, and high-intensity ultrasound can
have the following effects:

* Cavitation: Very high negative acoustic pressures can cause temporary
microscopic vacuum pockets. When these collapse, they produce very high local
temperatures that can cause damage to the immediate region.
* Heat generation: Local tissue absorbs the ultrasound energy and increases
their temperatures. Long-duration elevated temperatures above 41 C can damage
tissue.
* Bubble formation: dissolved gases come out of the solution due to local heat
increases.

Heat and cavitation are the two primary known detrimental bio-effects and
for this reason, the use of ultrasound is regulated by government agencies.

Ultrasonography is generally considered a “safe” imaging modality. However
slight detrimental effects have been occasionally observed.

Got that? The fetus-fetishists want to expose the sacred fetus (and the
woman of course) to ’slight detrimental effects’ in order to convince her to
continue the pregnancy and perhaps give birth to a slightly damaged infant.
Makes perfect sense, doesn’t it?

We at Birth Pangs, however, have more respect for women and fetuses. Well,
to be absolutely truthful, actually we fear assault charges and malpractice
suits. In jurisdictions other than South Carolina, forcing a person to undergo
invasive, potentially harmful ‘treatment’ of absolutely no therapeutic value
would be considered assault, and in this case, perhaps even sexual assault.

Medical professionals who carried out such treatment would have their asses
hauled into court and before every professional association they belonged to.

And because the most likely people to bring such suits and charges are
better-off, better-educated women, we at Birth Pangs, like the
fetish-fetishists in the US, would focus our efforts on younger, poorer, less
well-informed women, who could probably be shown a murky photo of a hot dog in
a mug of root beer and be convinced it was a human being.

So, listen up, Canada,
when politicians like Elizabeth
May offer ‘nuanced’ positions on abortion. Positions that call for ‘fewer’
abortions rather than accessible and safe abortions. Positions that recommend
waiting times and counselling. Positions that denigrate unwillingly pregnant
women as insane and desperate. Positions that would deny a certain class of
humans — women — the basic human right to control their own bodies.

Listen well. Because if we go that route, can forced ultrasounds be far
behind?

PURPOSE: The purpose of this
analysis was to determine the impact on specific forms of neonatal morbidity
and mortality by allowing women to opt for delivery by elective cesarean
section at 39 weeks of gestation (EGA). According to the National Vital
Statistics Reports, over 70% of deliveries in the U.S. annually are at gestational
ages>or=39 weeks EGA. Estimating that over 4 million deliveries occur
annually in the United
States, this would yield approximately 3
million pregnancies wherein the woman may exercise her choice for either
primary or repeat cesarean section at 39 weeks EGA or at the point when labor
is established. METHODS: A search was conducted using Ovid Medline spanning the
past 10 years using the following key words: fetal trauma, shoulder dystocia,
brachial plexus palsy, neonatal skull fracture, obstetrical trauma, traumatic
delivery, intrauterine fetal demise, stillbirth, fetal demise, and neonatal
encephalopathy. Using this search technique, over 2100 articles were
identified. The abstracts were reviewed and pertinent articles were chosen for
further consideration. The identified articles and their applicable references
were obtained for inclusion in this review. Preference was given to
publications on or after the year 2000 with the exception of classical or
sentinel articles, which were included without regard to year of publication.
RESULTS: Four major categories of neonatal morbidity and mortality are
discussed: Shoulder dystocia: Accepting that we do not have a successful method
for the prediction or prevention of shoulder dystocia, the question becomes,
"What is the chance that a baby will sustain a permanent brachial plexus
injury at delivery?" Additionally, is there a significant protective effect
of cesarean section in reducing the risk of such injury? Currently, the
occurrence rate of brachial plexus palsy at the time of vaginal delivery ranges
from 0.047% to 0.6% and for cesarean section from 0.0042% to 0.095%. Using a
composite estimate of the risk of 0.15% for vaginal deliveries and applying it
to the 3 million deliveries>or=39 weeks EGA, approximately 4500 cases of
brachial plexus palsy would occur. If only 15% of these injuries were
permanent, 675 permanent brachial plexus palsies would occur annually. If the
risk of permanent injury is 1 in 10,000 as reported by Chauhan, 300 permanent
brachial plexus palsies would occur annually in the United States. The range then for
permanent brachial plexus injury that could be avoided with cesarean section on
request would appear to vary between 1 in 5000 and 1 in 10,000 vaginal births.
Fetal trauma: The incidence of significant birth trauma varies from 0.2 to 1 to
2 per 1000 births. The use of sequential instruments, for example, vacuum
followed by forceps or vice versa, is specifically associated with an
unacceptably high injury rate. Intrapartum-related neonatal deaths of vertex
singleton fetuses with birthweights>2500 g from traumatic cranial or
cervical spine injury secondary to vacuum- or forceps-assisted vaginal delivery
are still occurring. Overall, the frequency of significant fetal injury is
significantly greater with vaginal delivery, especially operative vaginal
delivery, than with cesarean section for the nonlaboring woman at 39 weeks EGA
or near term when early labor has been established. Neonatal encephalopathy:
The prevalence of moderate to severe neonatal encephalopathy is 3.8/1000 term
live births with a neonatal fatality rate of 9.1%. In 4% to 10% of cases, the
etiology appears to be pure intrapartum hypoxia. Intrapartum hypoxia
superimposed on antepartum risk factors may account for up to 25% of the
moderate to severe encephalopathies, according to one cohort. A paradox in the
data thus far is that infants born to nonlaboring women delivered by cesarean
section had an 83% reduction in the occurrence of moderate or severe
encephalopathy. Considering a prevalence of moderate or severe neonatal
encephalopathy of 0.38% and applying it to the 3 million deliveries occurring
at >or=39 weeks EGA in the United States annually, 11,400 cases of moderate
to severe encephalopathy would occur. The rate of encephalopathy observed in
infants delivered by cesarean section would yield approximately 1938 cases.
This net difference in moderate to severe encephalopathy would represent 9462
cases annually in the United
States that could be prevented with elective
cesarean section. Although cesarean delivery may be protective for the
development of neonatal encephalopathy, to date it has not proven to be
protective of long-term neurologic injury in the form of cerebral palsy with or
without mental retardation and/or seizure disorders. Intrauterine fetal demise:
Copper reported that the rate of stillbirth is consistent from 23 to 40 weeks
EGA with about 5% of all stillbirths occurring at each week of gestation.
Yudkin reported a rate of 0.6 stillbirths per 1000 live births from 33 to 39
weeks EGA. After 39 weeks EGA, a significant increase in the stillbirth rate
was reported (1.9 per 1000 live births). Fretts reported on fetal deaths per
1000 live births from 37 to 41 weeks of gestational age, showing that the rate
progressively increased from 1.3 to 4.6 with each week of gestation. It can be
estimated that delivery at 39 weeks EGA would prevent 2 fetal deaths per 1000
living fetuses. This would translate into the prevention of as many as 6000
intrauterine fetal demises in the United States annually-an impact
that far exceeds any other strategy implemented for stillbirth reduction thus
far. CONCLUSION: It is reasonable to inform the pregnant woman of the risk of
each of the above categories, in addition to counseling her regarding the
potential risks of a cesarean section for the current and any subsequent
pregnancies. The clinician's role should be to provide the best evidence-based
counseling possible to the pregnant woman and to respect her autonomy and
decision-making capabilities when considering route of delivery.

OBJECTIVE: To compare
maternal and neonatal outcomes after induction, elective cesarean section and
spontaneous onset of labor in uncomplicated term nulliparous women. METHODS: A
total of 3751 uncomplicated term nullipara who delivered in Peking Union
Medical College
Hospital from Sept 2002
to April 2007 were retrospectively analyzed. They were divided into three
groups: the induction group, the elective cesarean section group, and the
spontaneous onset of labor group. Their general conditions (such as age, weeks
of pregnancy, hospital days and cost), postpartum complications (such as
postpartum hemorrhage, puerperal morbidity, urinary retention, blood
transfusion, delayed healing, and trauma), and Apgar score were compared by
statistic methods. RESULTS: (1) Among 3751 women, 501 (13.3%) of them underwent
induction( the induction group), 1634 (43.6%) delivered by cesarean section
(cesarean section group), the other 1616 (43.1%) women underwent spontaneous
onset of labor (the spontaneous onset of labor group). (2) Results of general
conditions: the spontaneous onset of labor group had the shortest hospital
days, which was longer in the induction group, and the longest in the selective
cesarean section group (P < 0.01). The selective cesarean section group had
the most cost during hospitalization, which was less in the induction group,
and least in the spontaneous onset of labor group (P < 0.01). Women who
undergwent emergent cesarean section after induction spent more money on
hospitalization than those who were in the selective cesarean section group and
the spontaneous onset of labor group (P < 0.01). (3) Puerperal
complications: (1) postpartum hemorrhage: the incidence of postpartum
hemorrhage was 3.0% (15/501) in the induction group, 0.6% (9/1634) in the
selective cesarean section group and was 1.2% (19/1616) in the spontaneous
onset of labor group (P < 0.01). (2 Urinary retention: the incidence of
urinary retention was 4. 6% (23/501) in the induction group, 0 in the selective
cesarean section group, and 3.3% (54/1616) in the spontaneous onset of labor
group. So the rate of urinary retention was lower in the cesarean section group
than in the other two groups (P < 0.01). (3) Blood transfusion: the
incidence of blood transfusion in delivery was 2.0% (10/501) in the induction
group, 0.1% (1/1634) in the selective cesarean section group, and 0.4% (6/1616)
in the spontaneous onset of labor group (P < 0.01). (4) Trauma: the
incidence of trauma in delivery was 0. 6% (3/501) in the induction group, 0 in
the selective cesarean section group, and 0.4% (7/1616) in the spontaneous
onset of labor group. So the rate of trauma was lower in the cesarean section
group than in the other two groups (P < 0.01). (5) Delayed healing: the
incidence of delayed healing of incision was 0.8% (4/501) in the induction group,
0 in the selective cesarean section group, and 0.2% (4/1616) in the spontaneous
onset of labor group (P < 0.01). (6) Puerperal morbidity: there was no
difference in puerperal morbidity among the three groups (P < 0.01). (7)
Neonatal asphyxia: the incidence of neonatal asphyxia was 1.2% (6/501) in the
induction group, 0.1% (1/1634) in the selective cesarean section group, and
1.0% (17/1616) in the spontaneous onset of labor group. The rate of neonatal
asphyxia was lower in the cesarean section group than in the other two groups
(P < 0.01). CONCLUSIONS: Induction may increase incidences of postpartum
hemorrhage and blood transfusion, yet, it does not decrease the incidence of
urinary retention and neonatal asphyxia. Generally, selective cesarean section
is safer than induction and spontaneous onset of labor, but it costs most.